Wiki ? dx

[Kimberley]

Pt has MRI brain w/wo...impression reads: normal appearance of the inner ear structures and cranial nerve eight bilaterally. Sinus disease as above.

Order history states vertigo, headaches and tinnitus.

since we scanned the brain, would it be appropriate to code sinus disease 473.9? Or should I just code the symptoms?

 

[kelleylawson]

Pt has MRI brain w/wo...impression reads: normal appearance of the inner ear structures and cranial nerve eight bilaterally. Sinus disease as above.

Order history states vertigo, headaches and tinnitus.

since we scanned the brain, would it be appropriate to code sinus disease 473.9? Or should I just code the symptoms?

I would code the sinus disease as this is a definitive finding. I would also code the signs and symptoms as they may or may not be directly related to the medical diagnosis of sinus disease.